Early Intervention for Mental Health of People with Minority Sexual Orientation

How can early intervention help support the mental health of lesbian, gay and bisexual people? 

Compared to heterosexual individuals, people who are lesbian, gay or bisexual have increased risk for mental health problems (1). In the past, same-sex sexual orientation was viewed as a mental illness in psychiatric diagnostic systems, but this is no longer the case. The World Psychiatric Association (WPA) states that it considers sexual orientation to be innate, that there is no sound research evidence that it can be changed and that it is unethical to try (2).
Prejudice, discrimination, victimisation and in some countries, legal sanctions including the death penalty, are likely to contribute to the mental health disparities. These experiences can cause stress, social exclusion and often result in the individual internalising the stigma, concealing their same-sex attractions or relationships and anticipating rejection from others. Such experiences, sometimes called ‘minority stressors’, may in turn contribute to mental health problems (3, 4).  They can also increase more general mental health risk factors such as low self-esteem, rumination (‘overthinking’) and avoidant behaviours (5, 6, 7).  In countries where same-sex behaviour is illegal, there can obviously be profound fear for the future, especially where there is capital punishment. Although some countries now have same-sex marriage and a relatively more accepting social climate, and people often make assumptions that the situation is much better for young people with a minority sexual orientation now, mental health inequalities are still found for lesbian, gay or bisexual youth (8).

“Coming out” at a younger age 
In many countries, youth are disclosing their sexual orientation at an earlier age than in the past. Benefits can include accessing social support and reduced concealment stress, but these young people are often exposed to stigma and victimisation at a younger age, when they have had less chance to develop positive self-worth and coping skills (8,9).

Self-acceptance, resilience and empathy  
When young people become aware that they experience same-sex attractions, there can be understandable adjustment difficulties as they may feel different, experience conflict with religious teaching and anticipate prejudice, discrimination or rejection. There can be self-acceptance challenges (10), but young people say that support from others who accept them can be very important in overcoming these. Over time young people can learn to value their differences and uniqueness. Many report that they feel their experiences have resulted in greater resilience in the long-term and more empathy for others who feel different or stigmatised.

Structural and system level changes to help reduce mental health inequalities
At a structural level, legal rights are vital, including legalising same sex orientation/behaviour and having hate crime legislation. School-based approaches could include anti-bullying strategies and teachers consistently speaking out against prejudice and conveying positive, accepting messages about people with same sex attractions in their lessons (11). Young people emphasize the importance of a wide range of different role models who have a minority sexual orientation, online and in daily life.

How might early intervention help?
Group or individual interventions could target self-acceptance and the development of social support systems with accepting others, especially if the young person experiences family rejection.  Other targets could include internalised stigma and support around coming out, if appropriate and safe in their social/political context. Group interventions designed to address the minority stress experiences of sexual minority youth may be helpful (12). Family-based interventions also require research.

Early intervention work could also address more general psychological risk factors such as low self-esteem, rumination and avoidance. For example, an individual cognitive behavioural intervention for sexual minority young adults with low self-esteem showed promising results (13).

For sexual minority people who have mental health symptoms already, it cannot be assumed that existing interventions work as well as for heterosexuals.  A national study in England found that lesbian and bisexual women, and bisexual men (but not gay men), benefitted less from psychological interventions for depression and anxiety than their heterosexual counterparts (14). The reasons are unclear, but such findings highlight the importance of therapist training regarding the needs of individuals with a minority sexual orientation. Promising results were reported for computerised cognitive behaviour therapy (CBT) adapted for the needs of depressed sexual minority youth (15).

Conclusions: Helping young people to build a positive future 
High quality research is needed into evidence-based interventions to support the mental wellbeing of people with a minority sexual orientation and help them to thrive. In the meantime, those supporting young people can try to help with their physical safety and protection from victimisation, coping skills for dealing with prejudice or discrimination, positive self-worth and social support networks, full engagement in education/work and social/leisure activities and if needed, access to effective mental health care.

Dr Katharine Rimes leads the LGBTQ+ mental health research group at the Institute of Psychiatry, Psychology and Neuroscience at King’s College London (KCL), UK. She is a lecturer in clinical psychology and director of the doctoral programme in clinical psychology. She is also an honorary consultant clinical psychologist in the UK National Health Service and an accredited cognitive behavioural therapist. She holds a BA in Experimental Psychology and a PhD from Oxford University. She researches the psychological processes involved in mental and physical illness and applies the findings to improve interventions. Her research interests include self-esteem and the impact of stigma. She has published over 100 articles in scientific journals.

You can follow Katharine on Twitter @KatharineRimes

References:

1. Plöderl, M. & Tremblay, P. (2015) Mental health of sexual minorities. A systematic review, International Review of Psychiatry, 27(5), 367-385, https://doi.org/10.3109/09540261.2015.1083949

2. Bhugra, D., Eckstrand, K., Levounis, P., Kar, A., & Javate, K. R. (2016). WPA Position Statement on Gender Identity and Same-Sex Orientation, Attraction and Behaviours. World Psychiatry, 15(3), 299–300. https://doi.org/10.1002/wps.20340

3. Meyer, I. H. (2003). Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence. Psychological Bulletin, 129(5), 674–697.

4. Argyriou, A., Goldsmith, K., & Rimes, K. (2021). Mediators of the disparities in depression between sexual minority and heterosexual individuals: A systematic review. Archives of Sexual Behavior, 50(3), 925-959. https://doi.org/10.1007/s10508-020-01862-0

5. Hatzenbuehler M. L. (2009). How does sexual minority stigma “get under the skin”? A psychological mediation framework. Psychological Bulletin, 135(5), 707–730. https://doi.org/10.1037/a0016441

6. Timmins, L., Rimes, K.A. & Rahman, Q. Minority Stressors, Rumination, and Psychological Distress in Lesbian, Gay, and Bisexual Individuals. (2020). Archives of Sexual Behavior, 49, 661–680. https://doi.org/10.1007/s10508-019-01502-2

7. Bridge, L., Smith, P. A., & Rimes, K. A. (2019). Sexual orientation differences in the self-esteem of men and women: A systematic review and meta-analysis. Psychology of Sexual Orientation and Gender Diversity, 6(4), 433-446. https://doi.org/10.1037/sgd0000342

8. Meyer, I.H., Russell, S.T., Hammack, P.L., Frost, D.M., Wilson, B.D.M. (2021) Minority stress, distress, and suicide attempts in three cohorts of sexual minority adults: A U.S. probability sample. PLoS ONE 16(3): e0246827. https://doi.org/10.1371/journal.pone.0246827

9. Russell, S. T., Toomey, R. B., Ryan, C., & Diaz, R. M. (2014). Being out at school: The implications for school victimization and young adult adjustment. American Journal of Orthopsychiatry, 84(6), 635–643. https://doi.org/10.1037/ort0000037

10. Camp, J., Vitoratou, S. & Rimes, K.A. (2020) LGBQ+ Self-Acceptance and Its Relationship with Minority Stressors and Mental Health: A Systematic Literature Review. Archives of Sex Behavior, 49, 2353–2373. https://doi.org/10.1007/s10508-020-01755-2

11. Rimes, K.A., Shivakumar, S., Ussher, G., Baker, D., Rahman, Q. & West, E. (2018). Psychosocial Factors Associated With Suicide Attempts, Ideation, and Future Risk in Lesbian, Gay, and Bisexual Youth. Crisis, 40, pp. 83-92. https://doi.org/10.1027/0227-5910/a000527

12. Craig, S. L., Leung, V., Pascoe, R., Pang, N., Iacono, G., Austin, A., & Dillon, F. (2021). AFFIRM Online: Utilising an Affirmative Cognitive-Behavioural Digital Intervention to Improve Mental Health, Access, and Engagement among LGBTQA+ Youth and Young Adults. International Journal of Environmental Research and Public Health, 18(4), 1541. https://doi.org/10.3390/ijerph18041541

13. Bridge, L. Self-esteem in sexual minority young adults: an investigation of factors affecting self-esteem and development of a new psychological intervention to improve low self-esteem. Unpublished PhD dissertation, King’s College London.

14. Rimes, K. A., Ion, D., Wingrove, J., & Carter, B. R. (2019). Sexual orientation differences in psychological treatment outcomes for depression and anxiety: National cohort study. Journal of Consulting and Clinical Psychology, 87(7), 577-589. https://doi.org/10.1037/ccp0000416

15. Lucassen, M. F. G., Merry, S. N., Hatcher, S., & Frampton, C. M. A. (2015). Rainbow SPARX: A novel approach to addressing depression in sexual minority youth. Cognitive and Behavioral Practice, 22(2), 203–216.
https://doi.org/10.1016/j.cbpra.2013.12.008

This project was made possible thanks to a sponsorship from H/Lundbeck A/S. The opinions expressed in these materials do not necessarily reflect those of H.Lundbeck.